MPs put the boot in ... again

Now the UK Parliament's Public Accounts Committee produces The National Programme for IT in the NHS: an update on the delivery of detailed care records systems.

This follows on from last week's report by the Public Administration Select Committee A Recipe for Rip-Offs - Time for a new approach which we reported on here.

The latest report (again only in html) recommends that the detailed care record database system is scrapped according to the BBC piece.

Ironic that on the one hand eveyone is condemning Tory-Lib proposals for NHS reform and on the other the NHS IT initiative, in its many aspects, is coming under such flack.

A Recipe for Rip-Offs

This has just been published by the UK Parliament's House of Commons Public Affairs Committee:
Public Administration Committee - Twelfth Report Government and IT- "A Recipe For Rip-Offs": Time For A New Approach". Unfortunately only available as html pages and not as an entire pdf. We will therefore give you the Summary ...

"Information Technology (IT) plays a fundamental role in the provision of public services. However, despite a number of successful initiatives, government's overall record in developing and implementing new IT systems is appalling. The lack of IT skills in government and over-reliance on contracting out is a fundamental problem which has been described as a "recipe for rip-offs".

IT procurement has too often resulted in late, over budget IT systems that are not fit for purpose. Given the cuts that they are having to make in response to the fiscal deficit it is ridiculous that some departments spend an average of £3,500 on a desktop PC. This Government, like many before it, has an ambitious programme aimed at reforming how it uses IT. This Report sets out what the Government must address if these reforms are to succeed where previous attempts have failed.

We found that government is currently over-reliant on a small "oligopoly" of large suppliers, which some witnesses referred to as a "cartel". Whether or not this constitutes a cartel in legal terms, current arrangements have led to a perverse situation in which governments have wasted an obscene amount of public money. Benchmarking studies have demonstrated that government pays substantially more for IT when compared to commercial rates. The Government needs to break out of this relationship. It should do this by:

i. Improving its own information. The Government's own information about its IT is woefully inadequate. This lack of data means that governments have failed to benchmark the price it pays for IT goods and services; this data must be collected centrally to allow the Government to obtain the best possible price from the market.

ii. Publishing more information. The Government has already started publishing large amounts of information about its expenditure as part of its transparency agenda. The Government should go further and make public not just information about how much its IT costs, but also about how its systems run. All IT procurement contracts should be published in full to ensure transparency and restore trust. This would allow external experts to challenge current practices and identify ways services could be delivered differently as well as more economically.

iii. Widening the supplier base. The Government must expand its supplier base by promoting fair and open competition and engaging with innovative SMEs. To widen the supplier base the Government needs to reduce the size of its contracts and greatly simplify the procurement process. It must also adopt common standards and ensure that systems interoperate to eliminate over-reliance on a small group of suppliers, and commoditise where possible. Most importantly, departments need the capacity to deal directly with a wider range of suppliers, especially SMEs.

iv. Working in an "agile" manner. The challenges that government seeks to address are constantly changing. Often the IT systems that government develops are already out of date before they have been implemented. The Government needs to move towards the use of agile and iterative development methods which enable IT programmes to adapt to changes.

Above all, to address these challenges successfully, the Government needs to possess the necessary skills and knowledge in-house, to manage suppliers and understand the potential IT has to transform the services it delivers. Currently the outsourcing of the government's IT service means that many civil service staff, along with their knowledge, skills, networks and infrastructure has been transferred to suppliers. The Government needs to rebuild this capacity urgently.

Finally, we outline our own vision for how the delivery of public services online could be reformed through a combination of data release, giving individuals control of their own personal records, engaging users in the design and continuous improvement of services and opening up the delivery of online services to a greater range of organisations.

The Government has set out its own milestones for success in its ICT Strategy. We shall be returning to this topic to monitor the Government's progress against these targets, and the recommendations set out in this Report."

The government did not want to tell me how much it was paying Microsoft for deliverables in the NHS IT programme when I made a FOIA request.

Reconfiguation

I thought reconfiguration is something I do to my computer - you know like moving from Windows to Linux. But it also happens in other areas of life. I guess you could call the current events in the Middle East and North Africa a "reconfiguration".

Now it applies to the NHS ... from the BBC:

"Changing hospitals - and in some cases closing parts of them - is the elephant in the room no-one dares talk about.

It is just too controversial. Hospitals are the visible face of the NHS and unsurprisingly people feel great affection for them. So when a particular unit is under threat they start to protest.

This has left many [politicians I guess] worried about putting the case for change - hence the ambiguous phrase the NHS uses to describe the process, reconfiguration."

The King's Fund, a health care think tank, that previously supported the previous government's shake-ups in the Greater Manchester area, is now warning against the current government's plans for the NHS with the intent of giving them more control/power of commissioning and reducing the role of hospitals in NHS decision-making. See the report.

The new NHS chief, Sir David Nicholson, (the new bogey man?) has warned

"Private sector take-overs, mergers and more community-based care may be needed to ensure all hospitals survive the shake-up of the NHS, the head of the health service says.

Sir David Nicholson told the BBC the combination of reforms and squeeze on spending meant some hospitals would find the future "difficult".

He said he did not expect any hospitals in England to close completely.

But said some would needed to adapt and change to remain competitive."

This begs the question of whether he will he be paying GPs more for their new responsibilities?

The National Programme for IT - "Gateway Reviews"

... otherwise known as "Connecting for Health" is the UK government's to produce one huge database of its citizens' healthcare ranging from booking an appointment with your family doctor to prescribing medication to keeping your medical records to ...

It has been widely critisised - by NHS staff, by the wider IT community, by politicians etc etc. Data security, contracting issues, technology, deadlines, training, consultation ... the list goes on.

The state treasury's Office of Government Commerce (OGC) has undertaken reviews of the project's status since its inception in 2002. These reports, known as Gateway Reviews have remained confidential, out of the public and media's eyes.

The magazine Computer Weekly submitted a Freedom of Information Act (FOIA) for these reviews to be published in public. Thirty one reports were published last week. Computer Weekly has a summary.

In 2005 responsibility for the project was passed from the Department of Health to five mega-conglomerates of regional Strategic Health Authorities (SHAs) The North West and West Midlands Cluster (NWWM) consists of six SHAs.

The Gateway Reviews highlight outstanding issues as with traffic lights - red, amber, green. In the NWWM Cluster of nine recommendations, one is green, five are amber and three are red.

The review was made in 2005.

The original project was budgeted at ₤5 billion - it is now ₤12 billion.

The head of IT at the Department of Health has stated that if no radical progress is made by November 2009, a radical "shake-up" will be necessary.

The NWWM Gateway Review of 2005 expected a further review for early 2006 - it was not published (or not done?). I have submitted a FOIA request to the OGC about this.

My previous FOIA request regarding how much Microsoft was earning from this project was rejected.

EDM 754 - Response from the Secretary of State for Health

I wrote to the Secretary of State for Health requesting him to sign EDM 754 regarding uptake of the MMR vaccine and media coverage. Although parliamentary guidelines advise that cabinet members do not normally sign EDMs, the guidelines do not forbid them from doing so. Here is Alan Johnson's response ...

DE00000390297

Dear Mr Gascoigne,

Thank you for your email of 13 February to Alan Johnson about the Early Day Motion (EDM) 754 on the MMR vaccine. As I am sure you will appreciate, Mr Johnson receives a large volume of correspondence and it is not always possible for him to respond personally. Your email has been forwarded to me for reply.

The EDM supports the Government’s position that all children should be vaccinated with two doses of MMR vaccine to protect against measles, mumps and rubella. You ask why Alan Johnson, Ed Balls and Gordon Brown have not signed the EDM. It may be helpful if I explain that Ministers and whips do not normally sign EDMs. Further information on who can and cannot sign EDMs is available on the UK Parliament website at www.parliament.uk (type ‘EDM’ in the search bar and follow the links).

The scientific community has been convinced for a considerable time that there is no link between MMR and autism. Just recently, three US judges who are experts in vaccine claim hearings concluded that there is no association between vaccines and autism. The overwhelming weight of evidence shows that MMR is the safest way to protect against measles, mumps and rubella, and the number of studies demonstrating this is growing. A list of the key studies examining MMR can be found on the NHS immunisation information website www.immunisation.nhs.uk, by selecting ‘The Vaccines’, followed by ‘MMR’ and ‘Research timeline’.

The Department of Health’s most immediate concern is that cases of measles are on the rise due to poor vaccine uptake over the past decade. The Department has an MMR catch-up programme now in progress and have provided extra funding to Primary Care Trusts, as well as additional supplies of the vaccine.

The message that the Department is promoting is that MMR is the safest way to protect children against measles, and that it will also protect them against mumps and rubella. Furthermore, it will also help protect those children who cannot have vaccinations for medical reasons.

I hope this reply is helpful.

Your sincerely,

Deepa Shah

Customer Service Centre

Department of Health

NHS Connecting for Health - Parliamentary Review

After the recent slamming of Lord Darzi's Next Stage Review by the UK Parliament's Health Committee, its Public Accounts Committee has just published its report The National Programme for IT in the NHS: Progress since 2006.

It is equally damning. I haven't finished it yet but reflecting my Freedom of Information Act denied request regarding how much the NHS pays Microsoft, the Department of Health also refused to reveal to the committee how much it is paying CSC for the development and (non-) deployment of the Lorenzo patient care record system.

To quote "Confidentiality agreements that the Department made with CSC in respect of two reviews of the delivery arrangemets for Lorenzo are unacceptable because they obstruct parliamentary scrutiny of the Department's expenditure ".

NHS Cancer Commissioning Toolkit

I tried to register on the NHS Cancer Commissioning Toolkit website yesterday.

Today I received this email:

Hi Angus

I’ve been sent your details by the Cancer Commissioning Toolkit team to ‘activate’ your registration. However, I need to know who your employing organisation is (this was blank on the user details) as users have to be employees of NHS organisations that have signed Data Access Agreements. Sorry if this sounds pedantic/bureaucratic, but there are currently some restrictions on access – but if you can confirm that you’re employed by an NHS organisation, then that’s not a problem!

Many thanks

Best wishes

PQ

Pauline Quennell

Network Audit Project Manager

GMCCN

My response:

Hi Pauline

As the Sector field in the registration form includes "NHS User", as I and my family are registered with a GP practice, as my daughter is undergoing treatment for leukaemia under the NHS and as only certain fields are asterisked, giving the impression these are the only ones that are obligatory, I assumed I would be eligible to sign-up for the Cancer Commissioning Toolkit.

However, I am not an employee of the NHS and therefore, as you explain, not eligible. Perhaps the CCT website designers could make this clearer.

Best wishes

Angus

The DoH document on Cancer Commissioning Guidance is here.

Three Government Departments

My FOIA request as to the cost of the DoH's contract with Microsoft received a pretty negative response.

I referred in a previous post to the National Audit Office's reports on the National Programme for IT in the NHS i.e. NHS Connecting for Health. In their first report, dated June 2006. the NAO had the following to say about the NHS contract with Microsoft:

"In November 2004 NHS Connecting for Health negotiated renewal of the Department's NHS-wide licence for Microsoft desktop products, which NHS Connecting for Health estimates will save £330 million over nine years with a firm commitment only for the first three years.
Microsoft agreed that the price paid by the NHS would continuously match the lowest charged anywhere in the world. The agreed price for their committed volume was substantially lower than that previously negotiated by the Office of Government Commerce (on a non-commitment basis) on behalf of UK government users. Microsoft also committed to spend £40 million on developing an NHS user interface to help standardise healthcare applications for clinicians, increasing efficiency and reducing the risk of clinical error.

NHS Connecting for Health also considered open source solutions for NHS IT but decided against doing so for two reasons;

The NHS already had an installed base of 500,000 Microsoft environments and users were familiar with Microsoft, and;
Open source solutions are not necessarily cheaper: they may be cheaper to acquire but the total cost of ownership is material when ongoing support, maintenance and training for users are taken into account."

The Office of Government Commerce (OGC) is a department of HM Treasury responsibly for providing advice to all government departments, both national and local, on contracting etc.

In 2002 it produced a report "Open Source Software - Guidance on implementing UK Government Policy". It followed this up with a report "Open Source Software Trials in Government".

It is widely recognised in the IT industry that Unix or "Unix-derivative" operating systems (e.g. Linux) are far more appropriate for servers, particularly webservers. Hence the DoH/NHS will be storing its electronic patient records on Unix (Solaris) servers using Oracle (rather than Microsoft's SQL Server or even the open source MySQL) as its database software.

The desktop environment is more controversial, it being cited that Linux desktops are "insufficiently mature".

The OGC seeked to examine this along with the cost benefits of using open source software (henceforth OSS).

I have some limited experience of deploying Linux desktops to regular users - my employer donated some legacy machines to respectively the national radio station, the national television station, a local primary school and the local municipal council's library.

The machines originally ran Windows NT 4.0. As a government organisation and as Microsoft no longer supports NT 4.0 we had to wipe the hard disks and, after some evaluation, I installed Xubuntu Linux (a light version of Ubuntu Linux suited to machines with small hard disks and little RAM).

The first deployment at the national radio station was a disaster - as soon as I turned my back they had a local technician come in and install a pirated copy of Windows XP.

At the television they took to it immediately - two machines for video editing with firewire ports so they could hook up their DVCAMs and download video clips using the open source KinoDV and edit them using the open source Cinelerra suite. Machines were also provided to the director's secretary and the admin. department - pleased as punch, OpenOffice and Mozilla Firefox no problem at all.

The machine offered to the director of the local primary school couldn't even handle the memory requirements of OpenOffice so I made Abiword the default wordprocessor. Both OpenOffice and Abiword will save documents in a variety of formats including MSWord doc and plain text txt (useful for blogging as Google's Blogger does not like doc embedded headers).

One of the case studies in the OGC report is particularly relevant to this post - that of the Beaumont Hospital in Dublin, Ireland.

Prior to its adoption of OSS it operated a mixed environment of MS Windows and Unix. The hospital had 3000 directly employed staff, and used 22 Linux servers, 14 Windows servers, a Hewlett-Packard HP3000 mainframe for primary clincal applications and a HP Unix system for financial applications. In 2002 there were 1000 workstations.

The hospital was experiencing severe financial problems and started to look at where it could make cost-savings - including in IT.

The IT department came up with the following results and subsequent implementation, between using OSS and proprietary Closed Source Software:


Email, online forms, laboratory procedures and results, patient care records etc - and even X-ray imaging - could all be dealt with by OSS.

There was some resistance to the Linux desktop GUI - Beaumont purchased an e-learning course to deal with this.

GUIs (there are various) have come a long way in the six years since Beaumont made the change. As I related above, our relatively unsophisticated IT users here in Sao Tome have taken to the Ubuntu-family GUIs as ducks to water.

The OGC strongly recommends that government entities should not tie themselves into closed proprietry systems - the NHS have chosen to do just that!

NAO and the NHS CfH

The DoH pointed out the opinion of the National Audit Office (NAO) that the Enterprise Wide Agreement between Microsoft and the NHS represented considerable savings to the taxpayer over normal Microsoft rates and those charged by Microsoft to other government departments.
There are two NAO reports evaluating CfH:

1. "The National Programme for IT in the NHS" (ref. HC 1173 June 2006).

2. i) "The National Programme for IT in the NHS: Progress since 2006" (ref. HC 484-I May 2008)

ii) "The National Programme for IT in the NHS: Project Progress Reports" (ref. HC 484-II May 2008).

These are hefty reports and it will take me some time to get through them.

Microsoft and the DoH - Random Thoughts

What do you and I think of this?

Here are some of my random of my thoughts ...

1. It was passed up from the NHS Connecting for Health (CfH) Freedom of Information Officer (FIO) to the Department of Health FIO. Does this say anything about DoH planning and contract awards? Or does this say something about the control of information in the NHS/DoH? The implication is that the contract is between NHS CfH, not the DoH, and Microsoft. However, it may be that the DoH administers the contract on behalf of NHS CfH.

2. The answer to my Question a) raises a number of issues. We are told that under the terms of the Enterprise Wide Agreement (EWA) with Microsoft the government is not allowed to reveal its cost – hardly seems to be in the spirit of open government.

In the first paragraph of this answer we are assured that the National Audit Office (NAO) considers the EWA good value for money compared to contracts between Microsoft and other government departments – this does not say much for these other contracts. Are they also subject to non-revelation of price clauses? Was the NAO's opinion declared publically?

The lack of openness seems to be in direct contradiction of all the government's hype about the free market and open competition.

With twisted logic it is argued that the non-revelation of the contract price results in a cheaper price and thus a lower burden to the taxpayer. What if Microsoft had to compete transparently? What price Freedom of Information?

This rather seems to mirror the European Union's concerns at Microsoft's monopolistic practices. Was the original EWA an open tender? If so, were there any other bidders? What were the terms of the 3-year extension clause? Is Microsoft undercutting, at a loss, potential competitors in order to gain a monopoly in the NHS? By the time this renewal (2007-2010) of the EWA is up, then the NHS will be so intricately tied into Microsoft systems that it will be obliged to renew again and again ... and Microsoft will have the NHS by the short-and-curlies and be able to charge whatever it wants.

3. The answers to my questions b) and c) are somewhat surprising and inadequate. From the Microsoft NHS website I have since learned that Microsoft has an EWA reseller programme divided up by Strategic Health Authorities.

The SHAs are distributed among three companies hence:

Bytes Technology Group:

North West SHA,
West Midlands SHA,
London SHA
South West, South East and South Central SHAs

Please contact Bytes Technology Group at:
nhs@bytes.co.uk
0208 786 1570
http://www.bytes-publicsector.co.uk/nhs

Computacenter Ltd.
East of England SHA
East Midlands SHA
Or as part of any Arms Length Body

Please contact Computacenter Ltd at:

nhs.microsoft.ea@computacenter.com
0800 055 6661
www.computacenter.com/nhsea

Trustmarque Solutions

North East SHA
Yorkshire andtThe Humber SHA
Department of Health

Please contact Trustmarque Solutions at:

Microsoft.Licensing@Trustmarquesolutions.com
0870 121 0322
www.trustmarquesolutions.com

Clearly, Microsoft's criteria for the selection of resellers and their remuneration are not going to be in the public domain.

I also discover that, as stated in the FIO's reply, that individual NHS entities, can enter “individual contracts” with Microsoft under its Select Licensing programme, without reference to CfH or the DoH. This programme is also administered through Microsoft resellers (generally the same ones as under the EWA) who are administratively organised by SHA. Surely the EWA should cover all NHS Microsoft needs? If CfH/DoH does not know how many of these contracts are held and what they are for, how can it plan for the EWA? How does it know whether the EWA is covering NHS needs?

4. I am somewhat relieved the planned Personal Care Record database will be stored on Solaris Unix servers using an Oracle database rather than Windows servers using MS-SQL database server software. With and by whom is/are the Solaris/Oracle contract/s held? What are the effective dates of such contract(s)?

The DoH FIO's reply seems to raise more questions than it provides answers.

Dear Readers - should I pursue this with a further FOIA request? If so, what should I request? Suggestions please in the comments or by email.

FOIA - Microsoft and the DoH

The reply ...

Our ref: DE00000356344

15 October 2008

Dear Mr Gascoigne,

Thank you for your request for information, under the terms of the Freedom of Information Act 2000 (‘the Act’), about Microsoft as a supplier of IT products and services to the NHS, and as a supplier to NHS Connecting for Health in connection with the Summary Care Record (‘centralised patient record system’). Your request was received on 7 October and it has been passed to me for reply.

Please find answers to each of your requests in turn below:

(a) How much the NHS is paying Microsoft for licensing of Microsoft's Operating Systems and any support services directly provided by Microsoft?

The terms of the Enterprise Wide Arrangement (EWA) negotiated between NHS Connecting for Health and Microsoft on behalf of the NHS preclude our revealing the pricing details to parties outside of Government. This proviso reflects the fact that the information is commercially sensitive information, and as such is exempt under section 43 of the Act, which exempts information whose disclosure would be likely to prejudice the commercial interests of any person. However, I can confirm that the National Audit Office have accepted that the prices the NHS is paying under the EWA are lower than those available under other agreements with Microsoft negotiated by the Office of Government Commerce on behalf of Government departments.

Section 43 is subject to the public interest test. Considerations I have taken into account in deciding the balance of public interest in relation to your request are that disclosure would b e consistent with policies for open government and accountability for public expenditure. Disclosure would also illustrate value for money in the context of the National Programme for IT. Considerations for withholding the information are that disclosure is likely to mean that Microsoft would not give the NHS such preferential pricing in any future arrangement. Furthermore, other suppliers are likely to become wary of offering NHS Connecting for Health or the NHS (and potentially other public sector organisations) exceptionally favourable terms in future if they perceive the risk that they too may have their lowest prices revealed in response to ad hoc requests for their disclosure. Hence, the net effect of revealing these particular price details is likely to be to increase future costs for the public sector/the taxpayer.

(b) How many discrete contracts does the NHS have with Microsoft? If more than one, what products/services are provided under each contract and what is the cost of each contract?

(c) If 3rd-part vendors are contracted to provide support services for Microsoft products, how many such contracts exist, how are they administered, and what is their total value?

Neither the Department of Health nor NHS Connecting for Health collect information about the number, nature or value of any such separate agreements.

I should explain that the NHS is not a single organisation or legal entity. In addition to contracts held centrally on behalf of the NHS as a whole, each NHS organisation is at liberty to enter into further bilateral agreements with Microsoft or its commercial partners for products or services to meet their local needs without the knowledge, or need for approval, of either NHS Connecting for Health or the Department of Health.

(d) What operating system is planned to be used on fileservers hosting the centralised patient record system, and with which core-database software is it being implemented?

I can confirm that the Summary Care Record sits on servers running the Sun Microsystems Open Solaris 10 ("Unix") operating system, in an Oracle 10g database.

If you have any queries about this letter, please contact me. Please remember to quote the reference number above in any future communications.

If you are unhappy with the service you have received in relation to your request and wish to make a complaint or request a review of our decision, you should write to the Section Head of the Department’s Freedom of Information Unit at the following address:

Freedom of Information Unit

Department of Health

Room 334b

Skipton House

80 London Road

SE1 6LH

Email:freedomofinformation@dh.gsi.gov.uk

If you are not content with the outcome of your complaint, you may apply directly to the Information Commissioner (ICO) for a decision. Generally, the ICO cannot make a decision unless you have exhausted the complaints procedure provided by the Department. The ICO can be contacted at:

The Information Commissioner’s Office

Wycliffe House

Water Lane

Wilmslow

Cheshire

SK9 5AF

Yours sincerely,

Stuart Craig

Department of Health

Room 317

79 Whitehall

London SW1A 2NS

FOIA

It seems my Freedom of Information request to NHS Connecting for Health has been passed on to the Department of Health as I received this email today ...

Acknowledgement of case DE00000356344 received by the Department of Health.

Palliative Care

Dr Crippen posted yesterday on palliative care.

What is palliative care? Care for those who are dying - slowly. Faster or slower - it doesn't much matter as they are still in pain, need pain control drugs, need their incontinence cleaned up, need the bedsheets changed etc etc.

Most palliative care is for older people as their bodies begin to fail. Their partners and carers are of similar age and find it hard to cope. But there are also many middle-aged, young adults or children.

There are some government-funded NHS palliative care "hospices" around the country ... but not many. Dr Crippen informs me that most of the slowly-dying patients with no hope left are left in a geriatric ward at a hospital in the furthest bed from the nurses' desk in the ward (so they can't smell the shit).

The government has just announced it wants to encourage you to die in the comfort of your own home amongst your loved ones. Dr Crippen approves - if your 80 year-old spouse can cope with this, your GP, District Nurse, social worker etc can provide you with the support you need.

But the NHS cannot provide you with the support you need.

Encouraging us to die at home rather than in an under-funded and scarce resource is not, as Dr Crippen notes, a measure of government sympathy for those dying but another cynical attempt to cut NHS funding - in this case on hospital-beds, hospice space and resulting staffing etc

A.'s middle-aged active husband died of cancer at the same time as her 17 year-old daughter H. is going through leukaemia. A. now has no husband, three children and has to take her oldest child to hospital 50 miles away ...

So I will question the palliative hospice system (in the UK) - is a hospice for Kezia (4 years-old and alive and doing well), Lucia (17 years-old alive and doing well), Adrian Sudbury (27 years-old dying), Christian Jago (middle-aged and dead) etc etc going to have the same needs as that of the 60/70/80+ year old? Will there be a paedatric/adult/geriatric palliative care doctor/nurse? I doubt.

Christian and Colin Jago had to move from their idyllic home in NW Scotland into a grubby inner-city Aberdeen flat, and soon afterwards Christian had to move into a hospice to die soon afterwards ...

Update: article in the US Candlighters journal on palliative care for children.

High Quality Care for All - NHS Next Stage Review Final Report

Lord Darzi's opus magnum ("Document type: Command paper") was issued yesterday. I was only able to download all 84 pages of it today. I've read Prime Minister Gordon Brown and Secretary of State for Health Alan Johnson's salutory one page letters congratulating Lord Darzi on such a superb and visionary effort. I am now moving on to Lord Darzi's "Summary letter" of introduction. I am already reaching for my (ex-) teacher's red pen ...

Tom Reynolds has already made an initial comment as has Dr Crippen. I am awaiting Dr Rant. But it will probably take me from now until the end of the weekend (and thank your deity I have a public holiday on Friday) to read and digest it all.

And at the same time the Department of Health wants me to look at a whole bunch of "consultation" documents issued at the same time on a proposed NHS Constitution!

When do our elected representatives, our doctors and nurses, our paramedics and ambulance crews, Jane and Joe Public have time to read all this bullshit documentation? No wonder they have to bribe people to turn up to consultation exercises.

And now Lord Darzi has completed his report, can the government let him get back to his real job of laparoscopy (keyhole surgery)?

NHS Overhaul

Talking about fuckwits ... Lord Darzi's final report (actually two documents - here and here - all 36 pages) is out. You'll have to wait until Monday for my opinion but for the time being the Guardian will have to suffice.

The Expanding Nurse

The baseline qualification for a Paediatric Oncology Nurse is course ENB 240: Care of Children with Cancer.

Which drugs do or don´t mix, drug safety issues, a specialist oncology nurse, more often than not, is more skilled than a doctor or a general nurse in finding that vein for an injection, to know that you don´t give an analgaesic to a febrile oncology patient, how to clean or draw blood from a Hickman Line and much much more.

On average 35.7 % of paediatric nurses working in units with child cancer patients are qualified at the ENB 240 level. I wish it was more.

Some of the nurses on the Borchardt Ward and Clinic at the Royal Manchester Children´s Hospital are trained or are being trained in the special skills of caring for children with cancer. I will assume the national average of 35.7 %. As most treatment for both in-patients and out-patients is on the day-shift, most of that 35.7 % is going to be on the day-shift. I wonder if the leading evening/night shift nurse is ENB 240 qualified.

Can´t we be told ? Can´t the hospital say we abide to such and such a standard which I can then look up ? Do I have to feel guilty at going to the PALS service ? How can I find out how many ENB 240 nurses exist on the Borchardt Ward ?

Drs Crippen and Rant have commented on and criticised many many times on the NHS use of Nurse Practitioners being allowed to make clinical decisions.

Fortunately, no nurse, ENB 240 qualified or not, on the Royal Manchester Childrenś Hospital cancer ward/clinic has ever made a clinical decision about our daughter. The paediatric cancer specialist nurse at the RMCH knows his/her limits and will call the doctor, even if it is the trainee night-time locum.

Drs Crippen and Rant - you should not be complaining at Nurse Practitioners, Nurse Specialists etc - we need more of them (35.7% is pathetic).

However, you are right to complain at the government´s policy to ¨expand¨ the nurse´s role into diagnosis and clinical work as a cheap alternative to using or training doctors

So give the specialist nurse practitioners a break, ok ?

Obviously, Nurse Practitioners, Specialist Nurses and all their variations are as much as part of the general population as GPs, consultants, patients, carers, nurses and are as susceptible to government/DoH/NHS spin as ¨John and Janet¨. Given ¨expanded¨ responsibility (clinical and diagnostic decision-making - a little bit of power ) it is, of course, in your job description against which you will be evaluated ...

The issue here is that the government is trying to hide its holes in clinical provision - in its budgetary concerns, its capital investments rather than day-to-day running costs, MTAS etc etc.

... rather than training nurses to be specialists within nursing and training doctors to be specialists within doctoring.

Perhaps the Royal College of Nursing should say something ... or perhaps they are as pathetic as the BMA.

BMA GP Poll

The results of the British Medical Association's General Practioner Poll on the provision of Out of Hours services are out - the GPs are not happy.

To GP or not to GP?

... or do we Polyclinic at Asda?

I can imagine the four of us going down to Asda on Saturday morning and myself saying ¨You get the sprouts Nanda ... I´m just popping into get my blood pressure taken and then a new prescription for Adalat to keep it down¨.

Unlike the queues at Asda´s check-out, I face a queue at check-in.

20 minutes later I pass the ¨till¨ although unlike Asda, the NHS is free at the point-of-entry, free at the point-of-need etc etc.

I finally see a doctor. I have never seen him before. A locum is substituting for the normal salaried doctor who is off sick.

¨Ah Mr .... Good Morning. I see you have a history of high blood pressure and that you´ve been taking Adalat ...¨, he comments turning his head briefly from the computer screen.

Oh shit ... I imagined that last paragraph. Rewrite.

¨Doctor I was too lazy and inconvenienced by my GP´s opening hours to get down there at 6 pm yesterday and get a prescription for my high blood pressure¨.

¨Let´s look up your history ...¨

As per usual NHS IT is Spineless ... he cannot access my records ... in Asda on a Saturday morning ...

¨Hmm ... (as I cannot access your records and don´t want any litigation) I would like to run some tests. But there´s no nurse here this morning so I suggest you go and see your GP on Monday or you could, of course, trundle down to A & E ...¨

I am between the ages of 18 and 60, employed and one of the 4% (the Department of Health tells me) who would like to visit a GP on a Saturday morning (sure as hell beats the fuck out of traipsing round Asda with Nanda, Kezia and Jaime!).

Bypassing on-going negotiations (which will include a ballot of members) with the doctors trade organisation, the stuffy fuddy-duddy British Medical Association (BMA) who have in principle rejected the government´s proposal that GPs provide an extra 3 hours of Out of Hours (OOH) work per week for no compensation, our Secretary of State for Health, Alan Johnson, ¨personally¨, wrote to every GP in the country ... and put the boot in!

Reneging on a GP contract it negotiated, accepted and signed, thinking it would be able pick up OOH through the Primary Care Trusts without providing the PCTs with any extra money, in the face of its own abject failure to provide OOH primary care, and its increasing pressure on PCTs to cost-cut by closing local A & E services, it now wants to backtrack.

The spin to brainwash Joe and Jane Public, in spite of the evidence of the Department of Health´s own surveys, started with Patricia Hewitt - a new generation of spin and confrontation has begun.

Methinks this will go to the High Court.

The Darzi Report, Government Spin and the Media

Lord Darzi’s interim report for the government’s consultation exercise “our NHS, our Future” has been published – a week earlier than scheduled. Its publication was cynically criticised by the political opposition as a measure taken prior to the Prime Minister’s weekend non-decision to not call a non-snap election (and yes, you can call my triple negatives into doubt!). They really missed the point.

I am somewhat surprised that Drs Rant and Crippen have not provided us more of their feelings about this report … maybe they are still fuming, maybe they are lost for words, maybe they are far too busy (on the golf course clearly) …

I will not attempt a detailed analysis of Lord Darzi’s informed report, the result of numerous public consultation meetings to which the Great British (and Northern Irish ?) public have had to be bribed to attend. Surely, Drs Rant and Crippen and many other heathcare professionals are far more qualified than I …

However, and subjectively, without a detailed media analysis, I observe that many of the issues on which our National Health Service needs to improve mentioned in Lord Darzi’s report, have been the subject of Department of Health press releases and thus media reports (if the BBC is anything to go by) over the last few months – mixed-sex wards, the supposedly hospital-transmitted infections of MRSA and C. difficile for which the DoH new and seemingly unproven “control” regulations were issued before the publication of Lord Darzi’s report, etc etc.

Last week our local hospital’s maternity unit, a modern building, was temporarily closed due to a cockroach infestation. Our daughter, receiving treatment for a immuno-depressed disease, is in a hospital constructed before Florence Nightingale, of which there are concerns regarding infection, of which there are concerns concerning cockroaches but maintains itself impeccable in the face of these challenges. The public sector trade union Unison claims 85 percent of NHS cleaning staff are overworked and underpaid.

Are such statistics in the Darzi report?

But perhaps the government’s biggest spin has been against General Practitioners’ (lack of) Out-of-Hours (OOH) service … regardless of the fact that recent DoH-commissioned surveys show the vast majority of the Great UK Public are satisfied with their GP services and that the government committed itself to provide OOH.

I am concerned that all this government spin has been to influence the Great UK Public, bribed to attend “our NHS, our Future” consultations who then regurgitate the government spin to Lord Darzi and his team and thus to the DoH and the government, who then make it policy!

And all over the country we are up-in-arms about the closure of our local services! But Gordon Brown and Alan Johnson won’t listen! Quality of Life is as important as Quantity of Life! Go read about Josie Grove and Davo. I hope you guys (and Patsy) get fuckin’ cancer … but of course your families all have flash cars to flash down to the nearest Centre of Excellence and can stay in a nice nearby hotel.

This week the government/DoH has finally but quietly admitted the failure of the Modernising Medical Careers-MTAS scheme by announcing new procedures for the recruitment/employment of trainee doctors, leaving the senior doctors, rather than the managers, to evaluate the junior doctors … and most importantly it will not involve a national online IT system that does not work.

But even this has a sting in its tail as the DoH announces a review of the employment of non-EU doctors, pandering to their own spin at the beginning of August which was designed to pander to the racist and bigoted opinion of some elements of the Great UK Public.

Yours disgusted.

I want to be consulted!

Dr Ray reported (and follow-up here) on Lord Darzi’s Citizen Jury consultations on the planned closure of NHS District General Hospitals and replacement with dumbed down polyclinics.

Apparently, the public delegates are not offered a reimbursement of their train tickets and tea and biscuits as they mingle with DoH staff after the main event. Nor are they even offered a buffet lunch.

No not at all!

After the medical delegates are shooed from the room, they are given £75 in cash!

And after Dr Ray’s exposure, the DoH actually admitted it!

DoH, invite me!